Vasculitic neuropathy following influenza
Neuropatia por vasculite após vacinação para influenza sazonal
Paulo J. Lorenzoni, Rosana H. Scola, Cláudia S. Kamoi Kay, Eustáquio de Queiroz, Juliana Cardoso,
Lineu C. Werneck
Neuromuscular Disorder Service, Neurology Division, Internal Medicine Department, Hospital de Clínicas da Universidade Federal do Paraná (UFPR), Curitiba
Correspondence: Rosana Herminia Scola; Serviço de Doenças Neuromusculares; Hospital de Clínicas da UFPR; Rua General Carneiro 181 / 3º andar;
80060-900 Curitiba PR - Brasil. ; E-mail: email@example.com
Conflict of interest: There is no conflict of interest to declare.
Received 02 August 2011; Received in final form 02 September 2011; Accepted 12 September 2011
Influenza seasonal vaccination is widely performed and
clearly justified on public healthy grounds. However, neuro-
logical complications have been reported following influenza
We describe a case of small vessel vasculitis with involve-
ment of skin and peripheral nerves after influenza seasonal
A 24-year-old woman presented 21 days after influenza
seasonal vaccination arthralgias on ankles and knees associ-
ated with skin rash in the legs. Four days after initial symp-
toms, she developed parestesia in her fingers, toes and lateral
region of right leg associated to weakness in left hand and
On physical examination, she had purpuric cutaneous rash
on both ankles and lower limbs (Fig A and B). Neurological
examination revealed weakness in left hand and right foot,
and diffuse reduction in deep tendon reflexes. Pain, pinprick
and light touch were impaired distally in the arms and legs,
more pronounced in region of left ulnar nerve and right per-
Laboratory tests, as well as serological tests, were normal.
Electrophysiological study showed an asymmetrical sensory-
motor axonal neuropathy consistent with multiplex monon-
europathy. Skin biopsy showed leucocytoclastic vasculitic
(Fig C). Sural nerve biopsy showed inflammatory perivascular
infiltration in the small vessel in epineurium and a reduction
1. Berg D, Godau J, Walter U. Transcranial sonography in movement
disorders. Lancet Neurol 2008;7:1044-1055.
2. Bor-Seng-Shu E, Fonoff ET, Barbosa ER, Teixeira MJ. Substantia nigra
hyperechogenicity in Parkinson’s disease. Acta Neurochir (Wien)
3. Berg D, Merz B, Reiners K, Naumann M, Becker G. Five-year follow-
up study of hyperechogenicity of the substantia nigra in Parkinson’s
disease. Mov Disord 2005;20:383-385.
4. Barsottini OG, Felício AC, de Carvalho Aguiar P, et al. Heterozygous
exon 3 deletion in the Parkin gene in a patient with clinical
and radiological MSA-C phenotype. Clin Neurol Neurosurg
5. Berg D, Jabs B, Merschdorf U, Beckmann H, Becker G. Echogenicity of
substantia nigra determined by transcranial ultrasound correlates
with severity of parkinsonian symptoms induced by neuroleptic
therapy. Biol Psychiatry 2001;50:463-467.
was found between the degree of SNH and the severity of do-
paminergic innervations impairment4; moreover, SNH seems
not to change during the course of PD, so that the progression
of PD cannot be monitored by TCS3.
Future longitudinal studies must address if SNH can
help to identify PD patients at preclinical stages mainly if
considered in conjunction with other nonmotor signs of PD,
such as depression, olfactory dysfunction, neuropsychologi-
cal deficits and idiopathic REM sleep behavior disorder5. If
this idea is true, PD could be identified before manifestation
of typical signs and symptoms, allowing development of neu-
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1. Schattner A. Consequence or coincidence? The occurrence,
pathogenesis and significance of autoimmune manifestations after
viral vaccines. Vaccine 2005;23:3876-3886.
2. Hull JH, Mead SH, Foster OJ, Modarres-Sadeghi H. Severe vasculitic
neuropathy following influenza vaccination. J Neurol Neurosurg
3. Uji M, Matsushita H, Iwata S. Microscopic polyangiitis after influenza
vaccination. Intern Med 2005;44:892-896.
4. Kelsall JT, Chalmers A, Sherlock CH, Tron VA, Kelsall AC. Microscopic
polyangiitis after influenza vaccination. J Rheumatol 1997;24:1198-1202.
5. Mader R, Keystone EC. Infections that causes vasculitis. Curr Opin
Fig. Purpuric cutaneous rash on both legs (A and B). Skin biopsy shows leucocytoclastic vasculitis (C: PAS stain). Nerve biopsy reveals
inflammatory perivascular infiltration in the small vessel in epineurium (D and E: congo red stain; F: SDH stain). Bar=50 um.
in the number of large myelinized fibers with axonal demy-
elination (Fig D, E and F). Muscle biopsy had inflammatory
reaction spread from infiltrated vessels to adjacent muscle fi-
bers associated to necrosis and phagocytosis.
The diagnosis of vasculitic neuropathy following influ-
enza seasonal vaccination was made and management with
prednisone (60 mg/day) controlled her disease and resulted
in marked and progressive improvement of her symptoms af-
ter four months.
All studies were done following informed consent.
Neurological complications have been reported fol-
lowing influenza vaccinations; however, disorders in-
volving the peripheral nervous system have been rarely
described1,2. Guillain-Barré syndrome is the most common
of the peripheral nervous system complications reported
after vaccination2. Recently, attention has focused again on
patients who developed vasculitic neuropathy as a compli-
cation of the influenza vaccination1. Vasculitic neuropathy
is characterized by a necrotizing vasculitis involving the
small arterioles of peripheral nerves. Although systemic
vasculitic can occur in a patient submitted to influenza
vaccination, there were only rare cases reports of influen-
za seasonal vaccination complicated with vasculitic neu-
ropathy, but are many the number of vaccinated patients
in the lasted years1-5.
We believe that influenza seasonal vaccination predis-
posed our patient to develop vasculitis in skin and nerve, but
the precise pathogenesis leading to the vasculitis following
vaccination is unknown. Two mechanisms of damage to ves-
sel wall have been suggested: a direct effect of the vaccine it-
self and an immunological activation.
Although treatment of vasculitic neuropathy after vacci-
nation remains empirical, our patient showed improvement
after adjustment of prednisone dose.